Esophageal Cancer

What is Esophageal carcinoma?

Esophageal carcinoma usually develops from the lining of esophageal squamous epithelial tissue.
Esophageal carcinoma is often caused by chronic inflammation in the esophagus that disrupts normal cell growth.
When the esophageal mucosa is exposed to carcinogens or mechanically damaged, the epithelial cells will grow abnormally, and develop into cancer.

What are the Treatment options?

Surgical removal of the esophagus is currently the only known way of curing most esophageal cancers.
In many cases surgery is combined with chemotherapy and radiotherapy before, and sometimes after, surgery to maximize the chances of cure.
Not everyone is suitable for this treatment so don't worry if you are just having surgery.
Early detection of small esophageal cancers can be removed via a gastroscopy.
Esophageal gastroscopy is a tube that passes via the mouth and therefore does not require any cuts.

What is Esophagectomy?

Esophagectomy means removal of the affected part of the esophagus. A portion of the healthy surrounding part will be removed as well as the upper part of the stomach.
The removal size will depend on the size and position of the cancer.
The remaining part of your stomach will be used to create a new tube and join to the upper end of the original esophagus.
The stomach, after the operation, will be placed more inside your chest than your abdomen but will function almost normally as before.
You may find the following schematic diagrams useful in understanding the operation.

Before esophagectomy After esophagectomy

Who will perform the procedure?

This procedure will be performed by myself.

Staging phase:

You will be seen in the clinic to be assessed and examined. then you will be referred to special tests to stage your cancer.

Diagnosis and staging procedures (you may have some or all the procedures below ) :

Telescopic Camera (Endoscopic) Examination to examine your stomach with a lighted tube.
Computed tomography (CT) scan and Endoscopic Ultra-sound examination (EUS) These give us an idea if you have a chance of curing you by surgery.
Positron Emission Tomography/Computed tomography (CT PET) scan.
Staging Laparoscopy (key-hole surgery).
Blood tests.

Hospital Phase:

Admission Day :(10 to 14 days)

You will be admitted to hospital on the day of surgery or one day before,

Make sure to bring all your medications.

You will be assessed by the surgical team including nurses, surgeons, anesthetists and may have some medication prescribed to you by the anesthetist.

You may be given a special stocking, to minimize the risk of deep venous thrombosis (DVT).

Operating Room: (4-8 hours)

Anesthesia team will (put you in sleep).
Insertion of lines to monitor you during and after surgery.
Shaving the surgical site (abdomen) and a patch area at your thigh.
Insertion of urinary catheter.
Insertion of feeding lines as needed.

During the procedure.

The aim of the operation is to remove the cancerous growth in the esophagus. This involves removing most of the esophagus. We usually use the stomach to replace the removed esophagus. The operation usually involves two to three stages.

Stage one:

Laparotomy: Some patients will have cut (vertical or transverse) across the upper part of the abdomen under the ribs.

Laparoscopy: Some patients will have keyhole surgery via 5-6 small cuts across the abdomen.

During this stage, the stomach is loosened from the attached tissues allowing it to be formed into a long tube, which will reach all the way from the abdomen up to the neck if needed.
This tube will act as the new esophagus later. Most patients will have widening of the stomach outlet to help with the drainage of the stomach after surgery.

Stage Two:

Right thoracotomy: You will have a cut on the right side of the chest by removing a segment of the rib for better access.

During this stage, the esophagus will be mobilized along with the surrounding lymphatics, and the stomach tube will be brought to the chest or neck and joined on to the remaining upper esophagus.
This procedure will allow you to swallow.

Stage Three:

Left lower neck incision is possible if the tumour is of high position that need to reach neck to have good clearance.

After the procedure

Waking up & sickness:

You will be shifted for an extensive observation in the Intensive Care Unit (1- 4 days) followed by shifting to the Surgical ward (6-8 days).

You may feel nausea, dizziness, headache, or vomiting after the surgery. If you feel sick, please inform the nurse and you will be offered medicine to relieve the symptoms.
you will have a small, plastic tube in one of the veins of your arm. This will be attached to a bag of fluid (called a drip), which feeds your body with fluid until you are well enough to eat and drink by yourself.

Drain/ Tubes: The reason to have these tubes is to prevent the collection of body fluids that may lead to infection.
1. Plastic drain: Each side of your chest (chest drains). These tubes are important to avoid your lungs collapsing immediately after the operation. The drains may stay for 3-7 days.
2. Gastric tube: You will have a tube passed in your nose. It will help to decompress the stomach after surgery. This tube is usually removed after surgery on days six to eight. The latter tube may also be used for feeding into the bowel as well to allow your esophagus to heal.
3. Feeding tube: will be administered because you can't or shouldn't receive feedings or fluids by mouth for at least seven days.
4. Jejunostomy tube: a fine plastic tube that will be placed either through the abdominal wall or into the bowel beyond the stomach.
5. Total parenteral nutrition (TPN) is a method of feeding that bypasses the gastrointestinal tract. A special formula given through a vein provides most of the nutrients the body needs.
6. The tube is removed either on the ward before you go home or at your first clinic visit two weeks after you go home.

Potential complications of the surgery:

Anastomotic leak (8%)

The joint between the remaining esophagus and the stomach tube is called anastomosis. The anastomosis does not remain water-tight.

Treatment: antibiotics, fine drain tube to be inserted, nil per mouth

- Small leak may resolve spontaneously after five to seven days

- In rare cases, transfer to the intensive care unit and/or require further surgery.

Pleural effusion

A fluid that collects between the lung and the chest wall.

Treatment:

- Insertion of chest drain tubes.

Pneumothorax or air leak

air accumulates in the chest cavity compressing the lung.

Treatment:

- Insertion of drain tubes

- In rare cases, surgical intervention

Chyle leak (1%)

a large lymph duct is accidentally damaged during surgery and accumulates in the chest.

Treatment:

- stop feeding via jejunostomy.

- after 2-3 days, the leak will stop completely.

- in rare cases, surgical intervention.

Stomach necrosis (1%)

Poor or no supply of blood supply to the stomach.

Treatment:

- surgical intervention.

- drainage bag.

- stop oral food, feeding via the jejunostomy.

- Swallowing liquids are allowed.

- After around 3-6 months, second surgery.

Chest infection (20%)

infection in the lungs or pneumonia.

Treatment:

-antibiotics.

-physiotherapy and breathing exercise.

- a chest infection is greatly increased if you smoke cigarettes.

Abnormal heart rhythm (5%)

heart palpitations, and an increase in pulse rate.

Treatment:

-balancing the body’s salt concentrations or

-medications.

Heart attack:

Damage to the heart muscle. The risk increase if you have history of heart problem or smoking cigarettes within 3 months of surgery.

Treatment:

-Close monitor.

-medications.

-Invasive intervention.

Complications of the feeding jejunostomy (1-5%)

-moving or leaking from the bowel where the tube has been inserted.

- the bowel may twist around the tube causing an obstruction.

Treatment:

-antibiotics.

- removal of the tube.

- in rare cases, surgical intervention.

Inoperability / Re-operation: (3%)

If there is advanced disease and signs of cancer spread, then the intended operation will not occur.

For any complication that necessitate to operate , then re-operation is always a risk, although very low.

Deep vein thrombosis (DVT) and pulmonary embolus

thrombosis (clots) in the deep veins of the legs in worse case its travel to your lungs.

Treatment

-Blood thinning injections

-Elastic stoking

- calves massaging device

-Mobilization

Damage to the bowel (intestines), spleen, major blood vessels (5%)

- damage to the spleen may occur that results in bleeding.

- Major surgery has a small risk of bleeding from a major blood vessel.

Treatment:

- surgical intervention.

Altered Voice

temporary hoarseness of the voice.

Recovery:

-recover over a few days to weeks.

-In rare cases, it may resolve over several months.

Wound hematoma

Bleeding under the skin can produce a hard swelling of blood clot.

Recovery:

disappear gradually or leak out through the wound without causing any major problem.

Wound Infection (4%)

the wound becomes red, hot, swollen, and painful, or if it starts to discharge smelly fluid.

Treatment:

- antibiotics

-Deep infection: antibiotic, or drain, or surgical intervention.

Recurrence:

Depending on the stage of the tumour and the margin status.

Anastomotic stricture

Narrowing in the join between the esophagus and small bowel loop.

Treatment:

- stretching of the join to make it wider.

Death (4%)

All major surgery carries a risk of death related to the procedure and the anesthetic.

Recovery:

Physiotherapy:

Early activity will reduce complications and shorten your hospital stay.

Deep breathing or coughing exercises will support your lungs and reduce the risk of a chest infection.
Sit upright in bed on the morning after your surgery.
Get out of bed and start walking around the ward on day 3.

Wound clips:

Any wound clips should be removed on days 10-14 after surgery.
Wound dressing will be performed by a wound care specialist at the clinic.

Discharge:

When the esophagus is removed, it is sent to the laboratory for examination.
Your results will be discuss in the (MDT) and your physician will be able to tell whether the surgery has cured the cancer or not.
You will have a detailed discussion with your consultant about this either before you leave the hospital or when you are seen in the outpatient department.

Recovery: After discharge:

Stay at home for a safe recovery from 3-6 weeks.
Stay on a pureed diet until reviewed by the surgical team in the clinic.
Monitor your weight (daily) and diet.
The clinical nurse specialist will call you to make sure about your progress.

Follow-up appointments and investigations:

Every three months for the first and second year. (+Blood tests)
Six months for the third year.
Annually the fourth and fifth years.
Every year from the date of surgery, you will have endoscopy (OGD) and CT scan until you complete 5 years from surgery.